Critical Access Hospitals. Objectives

Transcription

1 MeaningfulUse for Critical Access Hospitals Paul Kleeberg, MD, FAAFP, FHIMSS President, The Itinerant CMIO, LLC TASC HIT WEBINAR SERIES Tuesday, April 13, 2010 Objectives Understand the incentives and potential penalties for Critical Access Hospitals resulting from the Recovery Act Identify the proposed elements necessary to demonstrate meaningful use in order to achieve the incentives and avoid penalties Identify the steps necessary for successful implementation of an EHR in order to achieve the incentives 2 1

2 Outline The Recovery Act Financial Incentives for CAHs Elements of Meaningful Use Steps for Successful Implementation: The EHR selection process Communication Steps in workflow redesign Strategies of physician engagement Summing it up 3 History American Reinvestment & Recovery Act Fb February 2009 Major portion Health Information Technology for Clinical Health (HITECH) Act Defines a timeline and a process to move health care delivery into the information age 4 2

3 Placing our Bet on HIT: The Stimulus Package The stimulus package (Feb 2009) American Recovery and Reinvestment Act (ARRA) $787 B Health Information Technology for Economic and Clinical Health (HITECH) Act $29.2 B ($17.2 B net) starting in 2011 to incent Mdi Medicare and Mdi Medicaid participating id i physicians i and hospitals to use certified EHR systems in a meaningful way 5 Meaningful Use: Part of a Broader Agenda Funding Initiative CMS Incentives (Section 4201) For meaningful use Regional Extension Centers (Section 3012) Health Information Exchange (Section 3013) HIT Workforce Development (Section 3016) University-based Training; Community College Consortia; Curriculum Development Centers; Competency development Testing Beacon Community Program (Section 3011) Strategic Health information technology Advanced Research Projects (SHARP) - (Section 3011) Focus Incentive payments to eligible professionals and hospitals participating in Medicare and Medicaid programs that adopt and meaningfully use certified EHRs. Establish up to 70 Regional Extension Centers to support providers in adopting and becoming meaningful users of health information technology (HIT) Support state programs to ensure the development of health information exchange within and across their jurisdictions. Create several distinct programs that aim to support the education of HIT professionals. The goal is to train up to 45,000 new HIT workers to assist providers in becoming meaningful users of EHRs Create up to 15 demonstration communities to show how the meaningful use of EHRs can achieve measurable improvement in the quality and outcomes Achieving breakthrough advances to address welldocumented problems that have impeded adoption of HIT, including: the security, cognitive support, health care application & network-platform architectures, & secondary use of EHR data 6 3

4 The HITECH Act s Framework for Meaningful Use of Electronic Health Records (EHRs) Blumenthal D. Launching HITECH. N Engl J Med posted online Dec Meaningful Use Overview: Statutory Framework In HITECH, Congress established three fundamental criteria of requirements for meaningful use: 1. Use of certified EHR technology in a meaningful manner 2. Certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality and coordination of care 3. In using certified EHR technology, the provider submits clinical quality measures and other measures as determined by the secretary Source: Brian Wagner, Senior Director of Policy and Public Affairs, ehealth Initiative (ehi) presentation to the MN Exchange and Meaningful Use Workgroup January 15,

5 Broad Goals for Meaningful Use Vision Enable significant and measurable improvements in population health through a transformed health care delivery system. Goals 1. Improve quality, safety, efficiency and reduce health disparities. 2. Engage patients and families. 3. Improve care coordination. 4. Ensure adequate privacy and security protections for personal health information. 5. Improve population and public health. Source: Brian Wagner, Senior Director of Policy and Public Affairs, ehealth Initiative (ehi) presentation to the MN Exchange and Meaningful Use Workgroup January 15, Outline The Recovery Act Financial Incentives for CAHs Elements of Meaningful Use Steps for Successful Implementation: The EHR selection process Communication Steps in workflow redesign Strategies of physician engagement Summing it up 10 5

6 Incentive Program Key Provisions Eligibility Eligible Hospitals can receive both Medicare and Medicaid incentives Eligible Critical Access hospitals are only eligible for Medicare Incentives Eligible professionals must choose between Medicare & Medicaid Incentives, but may switch once Stage 1 Criteria for Being Deemed Meaningful user of Certified EHR 25 objectives and measures for eligible professionals (EP) 23 objectives and measures for eligible hospitals (EH) Criteria for Stage 2 & Stage 3 to be defined through future rulemaking EPs and EHs must meet all of the criteria. Reporting Mechanisms Of the 25 EP objectives, 7 require attestation; 18 require data submission Of the 23 EH objectives, 8 require attestation; 15 require data submission In 2012, CMS expects eligible professionals and hospitals to report clinical quality metrics electronically 11 Incentive Program Key Provisions (contd.) Timeframe for Demonstrating Meaningful Use (MU): In the 1st payment year, hospitals must demonstrate MU over any continuous 90 period in a fiscal year; for subsequent payment years hospitals must demonstrate MU over the entire fiscal year. In the 1st payment year, professionals must demonstrate MU over any continuous 90 period in a calendar year; for subsequent payment years professionals must demonstrate MU over the entire calendar year. Medicaid Incentives State Medicaid Agencies may propose an alternative definition of meaningful use for Medicaid incentives, however... States cannot propose fewer or less rigorous criteria States cannot propose alternative that would require additional functionality beyond that of certified EHR technology CMS must approve Medicaid Agencies proposed definitions Adapted from: Brian Wagner, Senior Director of Policy and Public Affairs, ehealth Initiative (ehi) presentation to the MN Exchange and Meaningful Use Workgroup January 15,

7 Meaningful Use Evolution The proposed rule lays out three stages to be applied to providers and hospitals seeking to receive incentive payments: The first stage will be applied to all those seeking to meet the requirements when the program launches in FY 2011 (hospitals) and CY 2011 (providers). Thesecondand third stages, which will be proposed in late 2011 and late 2013, will apply to providers and hospitals as they progress in their meaningful use of EHRs. Source: Brian Wagner, Senior Director of Policy and Public Affairs, ehealth Initiative (ehi) presentation January 15, Bending the Curve Towards Transformed Health Achieving Meaningful Use of Health Data Advanced clinical processes Improved outcomes Data capture and sharing Phased in series of improved clinical data capture supporting more rigorous and robust quality measurement and improvement Source: Connecting for Health, Markle Foundation Achieving the Health IT Objectives of the American Recovery and Reinvestment Act April

8 Definition of an Medicare Eligible Hospital A subsection (d) hospital defined in the Social Security At Act Essentially an acute care facility: Located in the 50 states Not a psychiatric, rehabilitative, predominately pediatric or cancer facility. Where average length of stay is 25 days or less 15 CAH s Medicaid Incentives Critical access hospitals are not eligible for Medicaid funding CMS defines an acute care hospital as: A section D hospital from the Social Security Act Has a Medicare CCN with the last four digits in the series 0001 through This excludes CAHs as well as psychiatric, rehabilitation, and long term care hospitals. There has been significant concern about this exclusion in during the comment period 16 8

9 Eligible CAH Medicare Incentives Reasonable EHR costs Medicare Share plus Reasonable EHR costs during the reporting period where the facility achieved meaningful use: (acquisition cost EHR soft/hardware) (depreciation + interest) The Medicare share (MS): Medicare inpatient days (total inpatient days ((gross revenue charity) / gross revenue)) Medicare Share plus: MS% + 20% or 100% whichever is less Paid on an interim basis for a maximum of 4 years or through 2015 Penalties: 2015 reasonable cost reimbursement reduced to %, % in 2016 and 100% in Medicare Incentives for Eligible Critical Access Hospitals Stage 1 Stage 1 Stage 2 Stage 2 Stage 3 Stage 3 Stage 3 Payment Payment Payment Payment Stage 1 Payment Stage 1 Payment Stage 1 Payment Stage 2 Payment Stage 2 Payment Stage 1 Payment Stage 3 Payment Stage 3 Payment Stage 3 Payment Stage 3 Payment Stage 3 Stage 3 Stage 3 Stage 3 Stage 3 Stage 3 Stage 3 Stage 3 Stage 3 Stage 3 Penalties for not achieving stage 3: Reasonable cost reimbursement of 101% would be reduced to: % % 100% Incentive payments calculation based on the Medicare Share of the EHR cost 18 9

10 Medicaid Considerations State Medicaid Agencies may propose an alternative definition of meaningful use for Medicaid incentives, however... Statescannot propose fewer or less rigorous criteria States cannot propose alternative that would require additional functionality beyond that of certified EHR technology CMS must approve Medicaid Agencies proposed definitions State specific MU definition would apply solely to EPs and children s hospitals Medicaid hospitals and eligible professionals can receive incentives for adoption, implementation and upgrade of certified EHR technology in their first year of participation in the incentive program Adopt, implement, or upgrade means: Install or commence utilization of certified EHR technology capable of meeting meaningful use requirements; or Expand the functionality of certified EHR technology capable of meeting meaningful use requirements at the practice site, including staffing, maintenance, and training. 19 Key Differences: Medicare & Medicaid Medicare CMS will implement (available nationally) Fee schedule reductions begin in 2015 for providers that are not Meaningful Users Must be a meaningful user in Year 1 MU definition will be common for Medicare Last year an EP may initiate program is 2014; Last payment in program is Payment adjustments begin in 2015 Only physicians, subsection (d) hospitals and CAHs Medicaid Voluntary for States to implement No Medicaid fee schedule reductions (but Medicare penalties still apply) Adopt/Implement/Upgrade option for 1 st participation year States can adopt a more rigorous definition (based on common definition) though hospitals only have to meet the Medicare definition if they participate in both Last year an EP may initiate program is 2016; Last payment in program is types of EPs, acute care and children s hospitals Source: CMS presentation January 20,

11 Outline The Recovery Act Financial Incentives for CAHs Elements of Meaningful Use Steps for Successful Implementation: The EHR selection process Communication Steps in workflow redesign Strategies of physician engagement Summing it up 21 Reactions to the Incentive NPRM Expand the number eligible providers to include those working in out patient clinics Allow Critical i laccess Hospitals to be eligible ibl for Medicaid idincentivesi Define the calculation of a hospital based EP as the encounter location and not as the charges Remove the reporting of quality measures from the stage 1 criteria until they can be done electronically Move medication reconciliation across care locations to 2013 Greater flexibility in meeting meaningful use criteria not all or none allowing EPs andehs the to defer non mandatory item from each category (bolded on the following slides) in the first year 22 11

12 Meaningful Use Criteria Health Outcomes Policy Priorities: Improving quality, safety, efficiency, and reducing health disparities Engage patients and families in their health care Improve care coordination Improve population and public health Ensure adequate privacy and security protections for personal health information 23 Improve quality, safety, efficiency and reduce health disparities Care Goals: Provide access to comprehensive patient health data for patient s health care team Use evidence based order sets and CPOE Apply clinical decision support at the point of care Generate lists of patients who need care and use them to reach out to patients Report information for quality improvement, public reporting 24 12

13 Improve quality, safety, efficiency and reduce health disparities Objective Ambulatory Measure Hospital Measure CPOE 80% of all orders 10 % of all orders eprescribe 75% of permissible scripts Demographics 80% of patients seen: language, insurance, gender, race, ethnicity, DOB 80% of patients seen: language, insurance, gender, race, ethnicity, DOB, date and cause of death Quality Reporting Report specialty specific quality measures to CMS or states Report specialty specific quality measures to CMS or states Drug Turned on (attestation) Turned on (attestation) Interactions Med List Med Allergies 80% of patients seen at least one or none 80% of patients seen at least one or none 80% of patients seen at least one or none 80% of patients seen at least one or none 25 Improve quality, safety, efficiency and reduce health disparities, cont. Objective Ambulatory Measure Hospital Measure Problem List 80% of patients seen at least 80% of patients seen at least one or none one or none Vitals 80% of patients seen: height, weight, BP, BMI, & for age 2 20: growth charts 80% of patients seen: height, weight, BP, BMI, & for age 2 20: growth charts Smoking 80% of patients age 13, record status Lab Results 50% of labs with numeric or +/ result in chart as structured t ddt data 80% of patients age 13, record status 50% of labs with numeric or +/ result in chart as structured t ddt data Patient Lists Generate pt lists (attestation) Generate pt lists (attestation) Reminders 50% of pts 50 sent reminders for follow up care 26 13

14 Improve quality, safety, efficiency and reduce health disparities, cont. Objective Ambulatory Measure Hospital Measure Decision 5 CDS rules relevant to the 5 CDS rules relevant to the Support specialty specific quality metric specialty specific quality metric Insurance 80% of patients seen 80% of patients seen Elegibility Electronic claim submission 80% of patients seen 80% of patients seen 27 Engage Patients and Families in Their Health Care Care Goal: Provide patients and families with timely access to data, knowledge, and tools to make informed decisions and to manage their health Objective Ambulatory Measure Hospital Measure Discharge info 80% of patients who request it (incl: d/c instructions, procedures) Visit summaries eresults ehealth summary 80% of patients seen get visit summary 10% patients seen with electronic access to lab results, prob lists, med list, allergies 80% of patients who request it (incl: test results, prob list, med list allergies) 80% of patients who request it (incl: test results, prob list, med list allergies. d/c summary, procedures) 28 14

15 Improve Care Coordination Care Goal: Exchange meaningful clinical information among professional health care teams Objective Ambulatory Measure Hospital Measure Exchange with providers Medication reconciliation Referral summary Electronic exchange of prob list, med list, allergies, test results. One attempt year one (Attestation) 80% of relevant encounters and transitions of care 80% of referrals and transitions of care Electronic exchange of prob list, med list, allergies, test results, procedures, d/c summary. One attempt year one (Attestation) 80% of relevant encounters and transitions of care 80% of referrals and transitions of care 29 Improve Population and Public Health Care Goal: Communicate with public health agencies Objective Ambulatory Measure Hospital Measure Immunization records One test of submission to state immunization registry (attestation) One test of submission to state immunization registry (attestation) Reportable labs One test of submission to state public health agency (attestation) Syndromic Surveillance One test of submission to state public health agency (attestation) One test of submission to state public health agency (attestation) 30 15

16 Ensure adequate privacy and security protections for personal health information Objective Ambulatory Measure Hospital Measure Protect Patient PHI Conduct or review a security risk analysis per 45 CFR (a)(1) and implement security updates as necessary (Attestation) Conduct or review a security risk analysis per 45 CFR (a)(1) and implement security updates as necessary (Attestation) 31 Quality Measures For Eligible Hospitals In 2011 payment year eligible hospitals will be required to report summary data to CMS on the set of clinical quality measures identified in Table 20 (next slides) For the 2012 payment year, hospitals will be required to submit these measures to CMS electronically to meet the requirements for both the Medicare and the Medicaid EHR incentive if eligible for both For hospitals eligible for only the Medicaid incentive program they will report to States For eligible hospitals to which the measures in Table 20 do not apply to their population, they have the option to select measures identified in Table 21 to meet the Medicaid reporting requirements Source: NPRM Section II (3) (f) 32 16

17 35 Quality Measures for EHs ED Throughput admitted patients Median time from ED arrival to ED departure for admitted patients ED Throughput admitted patients Admission decision time to ED departure time for admitted patients ED Throughput discharged patients Median Time from ED Arrival to ED Departure for Discharged ED Patients Ischemic stroke Discharge on antithrombotics Ischemic stroke Anticoagulation for A fib/flutter Ischemic stroke Thrombolytic therapy for patients arriving within 2 hours of symptom onset Ischemic or hemorrhagic stroke Antithrombotic therapy by day 2 Ischemic stroke Discharge on statins Ischemic or hemorrhagic stroke Stroke education Ischemic or hemorrhagic stroke Rehabilitation assessment VTE prophylaxis within 24 hours of arrival ICU VTE prophylaxis Anticoagulation overlap therapy Platelet monitoring on unfractionated heparin VTE discharge instructions Incidence of potentially preventable VTE Primary PCI Received Within 90 Minutes of Hospital Arrival Blood Cultures Performed in the ED Prior to Initial Antibiotic Received in Hospital Aspirin Prescribed at Discharge Source: NPRM Table Quality Measures for EHs Cont. Angiotensin Converting Enzyme Inhibitor(ACEI) or Angiotensin Receptor Blocker (ARB) for Left Ventricular Systolic Dysfunction (LVSD) Beta Blocker Prescribed at Discharge Hospital Specific 30 day Risk Standardized Readmission Rate following AMI admission Hospital Specific 30 day Rate following AMI admission Hospital Specific 30 day Risk Standardized Readmission Rate following Heart Failure admission Hospital Specific 30 day Rate following Heart Failure admission Hospital Specific 30 day Risk Standardized Readmission Rate following Pneumonia admission Hospital Specific 30 day Rate following Pneumonia admission Infection SCIP Inf 2 Prophylactic antibiotics consistent with current recommendations Ventilator Bundle Central Line Bundle Compliance Ventilator associated pneumonia for ICU and high risk nursery (HRN) patients Urinary catheter associated urinary tract infection for intensive care unit (ICU) patients Central line catheter associated blood stream infection rate for ICU and high risk nursery (HRN) patients All Cause Readmission Index (risk adjusted) All Cause Readmission Index Source: NPRM Table

18 Outline The Recovery Act Financial Incentives for CAHs Elements of Meaningful Use Steps for Successful Implementation: The EHR selection process Communication Steps in workflow redesign Strategies of physician engagement Summing it up 35 The EHR selection process Assess Visioning and Strategic Planning by Leadership Where do you want to be as a business What do you want an EHR to do for you Readiness Assessment Assess the attitudes and skills of users Assess staffing and governance Financial assessment Inventory of current systems Create a draft work plan Plan Getting organized Selecta Project manager, and steering committee Create Job descriptions Get representation from across the hospital Facilitated planning Visioning involving representatives from across the hospital Create goals and timelines Change Management Change management Strategy Workflow and process redesign Requirement specifications i Business Case, TCO, ROI Functional, technical and standards Select Formal vendor selection Understand the marketplace Client / Server vs. remote hosting Selection criteria Key functional differentiators Conduct due diligence Request for proposal Narrow the field Site visits Contract negotiation Price and payment terms Legal review. Sign contract Celebrate 36 18

19 Outline The Recovery Act Financial Incentives for CAHs Elements of Meaningful Use Steps for Successful Implementation: The EHR selection process Communication Steps in workflow redesign Strategies of physician engagement Summing it up 37 Communication Critical for the success of the implementation Share your vision and strategic plan and how the EHR will enable this Communicate, communicate, communicate Continuous updates of the plans for the EHR implementation Cannot be too much Staff will have many questions prevent rumors from starting Keep all staff informed of all the decisions Keep your patients and the quality of the care you deliver central to your communications and why you are doing it 38 19

20 Outline The Recovery Act Financial Incentives for CAHs Elements of Meaningful Use Steps for Successful Implementation: The EHR selection process Communication Steps in workflow redesign Strategies of physician engagement Summing it up 39 Workflow Redesign Necessary because an EHR implementation will change the way people do things Do not merely automate current processes! Steps: Identify processes to be mapped Use individuals who actually perform the process Instruct them on why it is being done Map current processes Validate the maps Collect all forms and reports that are a part of the process 40 20

21 Outline The Recovery Act Financial Incentives for CAHs Elements of Meaningful Use Steps for Successful Implementation: The EHR selection process Communication Steps in workflow redesign Strategies of physician engagement Summing it up 41 Strategies of Physician Engagement Involve them early and communicate frequently Indicate the date that the hospital will have selected a CPOE system and that you want their involvement from the beginning Offer remote access as an incentive State benefits in a manner that is give and take, recognizing the value to both parties. Ask physicians to participate in: Measurable goal setting so they can influence the measures Scenario development so they have responsibility for assessing the products Standing order development to build their own order templates Review of the clinical effectivenessand efficiency with using the decision support rules. Workflow review Adopt the standing orders as soon as they are developed. If physicians are paid by the hospital, base future forms of compensation on achieving the goals

22 Outline The Recovery Act Financial Incentives for CAHs Elements of Meaningful Use Steps for Successful Implementation: The EHR selection process Communication Steps in workflow redesign Strategies of physician engagement Summing it up 43 What Hospitals Should Do Now (Begin with the end in mind) Create a group vision of where you want to be in 5 years Engage the entire staff in EHR implementation andoptimization Seek out the experience of others who have done it already Raise awareness that the transition, either installation or optimization, will be difficult, but worth it Involve employees and medical staff throughout the hospital in EHR governance, advisory committees, focus groups, design buildvalidate sessions, training opportunities, process improvement, etc. Begin to to clean up your process now so it is not blamed on the EHR Critical Access Hospitals will soon be able to leverage the HIT Regional Extension Centers for help. Take advantage of that 44 22

23 And what we all should do (Begin with the end in mind) We are doing this to: Improve the quality, safety and efficiency of care while reducing health disparities. Engage our patients and their families. Improve care coordination among all members of the team. Improve population and public health. Ensure adequate privacy and security protections for everyone s personal health information. 45 Resources: Meaningful Use information on the Health and Human Services web site: hh / i l Information about the HIT Extension Centers: ntname=communitypage&parentid=58&mode=2&in_hi_userid=1111 3&cached=true (or go to select HITECH Programs in the left column, then select Health Information Technology Extension Program ) Stratis Health Toolkit for CriticalAccess Hospitals: This presentation: cah/ 46 23

24 Meaningful Use for Critical Access Hospitals Questions Paul Kleeberg, M.D., FAAFP, FHIMSS President, The Itinerant CMIO